Central Venous Occlusive Disease Research Articles

Risk factors for in-stent restenosis in maintenance hemodialysis patients with central venous occlusive disease and biomechanical assessment of stents.

To investigate the risk factors and biomechanical mechanisms of in-stent restenosis (ISR) in central venous occlusive disease (CVOD). This retrospective study consecutively included 77 maintenance hemodialysis (MHD) patients with CVOD who received the first percutaneous transluminal angioplasty with stenting (PTS) due to symptomatic CVOD in a tertiary hospital. The mean age was 59.7 ± 14.0 years, and 51.9% of patients were male. The clinical characteristics, occurrence of ISR and patency rates were recorded. Finite element method was applied to assess the biomechanical properties of stents. Among 77 patients with a mean CVS score of 8.0 ± 2.8, 20.8%, 62.3%, and 16.9% of patients had the main vein of CVOD in the subclavian vein, brachiocephalic vein, and superior vena cava, respectively. A total of 72 (93.5%) patients received successful PTS treatment, for which the stents implanted were mainly Fluency covered stent (48.6%) and SMART bare stent (31.9%). During 15 (10-24)-months of follow-up, ISR occurred in 36.1% of the 72 patients. The primary and assisted primary patency rates at 6, 12, and 18 months were 78%, 56%, 42% and 95%, 90%, 87%, respectively. A prolonged dialysis vintage was an independent risk factor for ISR, yet the stent type or the main vein location was not correlated with ISR. Among three laser-engraving stents, the SMART stent was the best in terms of flexibility, stress, and strain on stents but worst in stress or strain on vessels. The Luminexx stent was the best in radial force and worst in stress or strain on stents. The Vici stent was the best in stress and strain on vessels and worst in radial force and flexibility. An unsatisfactory comprehensive biomechanical performance from configurations rooted in existing stents may account for the high incidence of ISR in CVOD.

Abstract No. 204 HeRO graft placement versus central venous stenting for arm swelling ipsilateral to AV access: a cost analysis from the payor’s perspective

In ESRD patients with AV fistulae or grafts, ipsilateral central venous occlusive disease can result in massive arm swelling resulting in significant morbidity. Treatment options include angioplasty, stent placement, access ligation, and more recently conversion of the access to a HeRO graft. Recent literature has demonstrated that conversion to a HeRO graft results in longer primary and secondary patency than central vein stent placement with equivalent efficacy for resolving arm swelling. Existing literature has compared the cost of the HeRO graft to thigh graft or tunneled catheter use, but there is no literature comparing the cost of HeRO graft to alternative strategies for arm swelling.

One-year outcomes and predictive factors for primary patency after stent placement for treatment of central venous occlusive disease in hemodialysis patients.

Objective:The study purpose was to determine the outcomes and factors predictive of primary stent patency for the treatment of central venous occlusive disease (CVOD) in hemodialysis patients.Methods:Data of 71 patients with CVOD treated with stent placement from January 2012 to December 2017 were analyzed. Univariate and multivariate analysis was performed to determine factors associated with stent patency. Adverse events related to stent placement were also examined.Results:The median primary patency duration of the 71 patients was 16 ± 2.2 months. The cumulative 3-, 6-, 9-, and 12- month primary patency rates were 93%, 72%, 55%, and 51%, respectively. Independent predictors of longer primary patency were vessel diameter > 12 mm, the use of a covered stent, and absence of vessel calcifications. Median primary patency of covered stents was 21 months as compared with only 10 months for bare stents (p < 0.001). Procedure-related adverse events occurred in 17 patients (21.8%), and four events (5.1%) required medical intervention. No life-threaten complications occurred.Conclusions:A vessel diameter > 12 mm, the use of a covered stent, and no vessel calcifications are independently associated with a higher primary patency rate after treatment of CVOD in hemodialysis patients.

Sharp recanalization for treatment of central venous occlusive disease in hemodialysis patients

BackgroundThe purpose of the present study was to evaluate the technical feasibility and safety of sharp recanalization for central venous occlusive disease (CVOD) in patients requiring hemodialysis. MethodsPatients with CVOD requiring hemodialysis who had undergone endovascular recanalization using sharp devices, including the stiff end of a guidewire, Chiba needle, or RUS-100 to cross occluded segments after conventional techniques had failed were included. The needle was guided toward a target placed at the opposite end of the occlusion. Although the guidewire was passed though the occlusion, subsequent procedures such as percutaneous transluminal angioplasty could be performed. ResultsA total of 27 sharp recanalization procedures in 25 patients were performed. Two attempts failed, 1 patient had undergone two separate successful procedures, and 23 procedures in 23 patients were successful. The overall technique success was 92.6%. The stiff end of a guidewire was the first choice for all the procedures, and recanalization was achieved in 18 patients (66.7%). A Chiba biopsy needle was used in six procedures (22.2%), with 100% technical success. A RUPS-100 set was used in two procedures (7.4%), with one aborted because of concern for complications. The occlusion was subsequently crossed using a Chiba needle. Four minor adverse events (two of mediastinal hematoma and two of chest pain) had occurred, and two major adverse events (pericardial tamponade and acute pleural effusion in one patient [4%], treated with the guidewire stiff-end technique, who recovered after drainage) had occurred. ConclusionsSharp recanalization is safe and feasible with high technical success for CVOD in patients requiring hemodialysis who cannot be recanalized using conventional techniques.

Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients.

To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Endovascular management of central venous occlusive disease in hemodialysis patients with symptomatic venous hypertension

Aim The aim was to evaluate the feasibility and efficacy of balloon angioplasty in hemodialysis patients with venous hypertension. Materials and methods A prospective study was carried out from April 2017 to October 2019 at 6 October Insurance Hospital, Cairo, and Sohag University Hospitals on 32 patients with end-stage renal disease on hemodialysis complaining of venous hypertension owing to central vein occlusive disease treated with balloon angioplasty with or without stenting. Bailout stent was deployed in cases of significant residual stenosis more than 30% or venous recoil. Results The commonest site of central vein occlusion was the innominate vein in 21 (65.6%) patients. Technical success was achieved in 26 (81.3%) patients; 20 of them operated by balloon angioplasty and six achieved after stent deployment. Technical failure occurred in six (18.8%) patients. Overall primary patency rate was 76.9, 57.7, and 46.2% at 3, 6, and 12 months, respectively. Primary patency rate was 80, 65, and 55% at 3, 6, and 12 months, respectively, in those treated with balloon angioplasty, whereas it was 66.6, 33.3, and 33.3% at 3, 6, and 12 months, respectively, in those treated with stent deployment (P=0.17). Reocclusion was recorded in 14 (53.8%) of 26 patients; nine of them were previously managed by balloon dilatation, whereas the other five patients were previously managed by stent deployment. Of 14 cases, 7 were managed successfully by balloon dilatation, 2 of 14 patients were treated by stent deployment, whereas in 5 of 14 cases, revascularization failed. Analysis of data of failed cases denoted that 4/5 of them were in-stent occlusions and one case occluded after percutaneous angioplasty. Conclusion Balloon angioplasty for central vein occlusive disease in hemodialysis patients achieves comparable patency rates and clinical outcomes to venous stent. Although it achieves short-term durability, it should be applied firstly reserving the venous stent for significant residual stenosis.

Evaluating a Novel Telescoping Catheter Set for Treatment of Central Venous Occlusions

Central venous occlusive disease (CVOD) is a prevalent problem in patients with end-stage renal disease (ESRD) and can lead to access malfunction or ligation for symptomatic relief. The purpose of this study is to evaluate the efficacy of the TriForce® Peripheral Crossing Set (Cook Medical), a novel reinforced telescoping catheter set designed to provide additional support for crossing difficult central venous occlusions. This is a single-center retrospective study from a quaternary referral center. We identified 37 patients over a 17-month period who underwent 56 attempts at endovascular recanalization for the treatment of central venous occlusion. Technical success rates, procedural data, and outcomes were compared between those undergoing recanalization using traditional wire/catheter sets versus the TriForce catheter set. Average age was 48±2years. Comorbidities were similar between the two cohorts and included ESRD (61%), deep venous thrombosis (30%), and May-Thurner syndrome (7%). Forty attempts were made with traditional wire/catheter sets and 16 attempts with the TriForce catheter set to treat 2.1±0.2 and 1.9±0.3 occluded venous segments, respectively (P=0.74). Technical success rates were significantly higher for the group undergoing recanalization using the TriForce catheter (69% versus 38%, P=0.04) and 4 patients were successfully recanalized using the TriForce catheter set after a failed attempt with traditional wire/catheter sets. Mean fluoroscopy time and radiation dose were 13±3min and 14,623±2,775μGy∗m2 for traditional techniques versus 30±6min and 30,408±10,433μGy∗m2 for the novel telescoping catheter set (P=0.01 and 0.09, respectively). Freedom from reintervention at 1year was 60% for the TriForce cohort versus 44% for the traditional wire/catheter cohort (P=0.25). The novel TriForce reinforced telescoping catheter set is a useful adjunct that may improve recanalization rates of CVOD compared with traditional wire/catheter sets.

Mid-term Outcomes of Patients with Central Venous Occlusive Disease Undergoing Surveillance Venography and Intervention

To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty (PTA) in haemodialysis patients presenting with central venous occlusive disease. A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing, respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3-6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient's demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively (P = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively (P = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively (P = 0.07). There was significant difference in the overall primary assisted patency (P = 0.048) between the CVO and CVS groups. CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme.

Role of Doppler Ultrasonography Supplemented with Direct CT Venography in Dialysis Access Assessment

Background Functioning dialysis vascular access is essential for end stage kidney disease patients Purpose To review the value of following a systematic DUS protocol of examination in DVA malfunction assessment. Through following this protocol, we will review the role of d-MDCTV examination in completion of DVA assessment in selected cases in which DUS assessment is incomplete. Patients and methods We evaluated 50 patients with malfunctioning DVA. The study population had been categorized into 2 groups; Group A (25 patients): was examined by DUS only, Group B (25 patients): was examined by DUS followed by d-MDCTV, using 8 channels CT scanner, with injection of 130-150 ml diluted contrast media into any accessible vein in the limb harboring dialysis vascular access Results Regarding both studied groups; different pathologies were diagnosed to cause DVA malfunction, (anastomosis/ venous thrombosis(17), anastomosis stenosis(5), peripheral venous stenosis(9), deep position of the VA(2), venous aneurysm/ pseudoaneurysm(8), branchouts(11), venous hypertension(5), arterial thrombosis(4), arterial stenosis(3), arterial aneurysm (4)& Dialysis induced limb ischemia(8). Diagnosis of these pathologies were almost well established by DUS alone As regarding the evaluation of central veins for group B patients; 18 patients were confirmed by d-MDCTV to have a central venous occlusive disease; the diagnosis in 4 of them was equivocal by DUS. 7 patients were confirmed by d-MDCTV to have a normal central veins; the diagnosis in 1of them was equivocal by DUS. Conclusion A systematic DUS examination protocol is the 1st line in DVA malfunction assessment. This assessment in certain cases is incomplete. We suggest that d-MDCTV can complete this assessment.

Efficacy and safety of a mother-child technique for recanalization of chronic central venous occlusive disease in hemodialysis patients

ObjectiveThere is no optimal treatment for central vein occlusive disease that remains a major contributor to vascular access impairment. This study aimed to review the outcomes of percutaneous treatment with a mother-child technique in the treatment of symptomatic central venous stenosis (CVS) and central venous occlusion (CVO) in patients on hemodialysis. MethodsData were collected retrospectively and included all consecutive patients with CVS or CVO who were treated with percutaneous angioplasty and stenting. The occlusive lesions were crossed using the mother-child technique with an angiographic catheter-in-guiding catheter system. ResultsA total of 36 patients with symptomatic CVS and 45 patients with total CVO were included. The average age and gender composition were similar between the two groups. Patients with CVO had higher prevalence of diabetic nephropathy than CVS (24.4% vs 5.6%; P < .05). Lesion success, device success, and procedural success were achieved in 36 (100%), 1 (100%), and 36 (100%) patients in the CVS group and in 43 (95.6%), 11 (100%), and 43 (95.6%) patients in the CVO group, respectively. There were no severe complications or procedure-related deaths in either group. During follow-up (median, 6 months), the primary patency rates were 89.7% (CVS) and 81.0% (CVO) at 6 months and were 54.2% (CVS) and 47.1% (CVO) at 12 months. The assisted primary patency rates were 100% (CVS) and 91.2% (CVO) at 6 and 12 months. ConclusionsWith extra backup support of the mother-child technique, percutaneous treatment provides an effective and safe method for recanalization of chronic venous occlusion in patients on hemodialysis.

Surgical management of central venous occlusive disease in hemodialysis patients

Background Central venous disease is a common and complex problem that compromises functioning access in patients undergoing hemodialysis which may result in loss of the access. Prior ipsilateral insertion of central venous catheters is a common risk factor. Percutaneous angioplasty with or without stenting is considered the primary method to treat central venous stenosis. However, it carries poor long-term patency rates and require multiple and repetitive interventions. Surgical options could be the choice if endovascular approaches are refractory or impossible. Aim The purpose of this retrospective, observational study is to report our experience in the surgical management to maintain hemodialysis access compromised by venous hypertension (VHTN) due to central venous occlusive disease. Patients and methods This is a retrospective analysis of 14 patients with existing upper extremity hemodialysis access who underwent extra-anatomic surgical bypass to treat symptomatic VHTN due to central vein occlusive disease after failure of endovascular management. Results Technical success was achieved in the 14 (100%) cases while clinical success occurred in 13 (92.6%) cases; 12 (85.7%) patients had performed their hemodialysis sessions via their preexisting access within 24 h postprocedurally. Maximum postoperative hospital stay was 3 days. No in-hospital morbidity or death was recorded. The mean primary and secondary patency were 18.3 and 22.7 months, respectively. Primary patency rates at 6, 12, 18, and 24 months were 85, 78, 64, and 57%, respectively. Secondary patency rates at 6, 12, 18, and 24 months were 92, 85, 71, and 64%, respectively. Conclusion Extra-anatomic surgical bypass of central venous obstruction is an effective and safe method to provide symptomatic relief of VHTN and salvage of existing access in hemodialysis patients when endovascular solutions are unfeasible.

Stent-Graft Length Is Associated with Decreased Patency in Treatment of Central Venous Stenosis in Hemodialysis Patients

Central venous occlusion may occur in hemodialysis patients, resulting in arm or facial swelling and failure of dialysis access. Endovascular management with balloon angioplasty or stenting has been described, but there are minimal data on the use of covered stents in this pathology. We sought to review a single institution's experience with the use of covered stents for central venous occlusive disease in hemodialysis patients. A retrospective review of all patients undergoing placement of covered stents between April 2014 and December 2016 for central venous occlusive disease to preserve a failing dialysis access was performed. Patients' records were reviewed to identify demographics, medical comorbidities, operative variables, primary patency rates, and secondary interventions. A total of 29 patients were included in the analysis. Viabahn (W.L. Gore and Associates, Flagstaff, AZ) stent grafts were exclusively used in all patients. Technical success rate was 100%. The patients were predominantly female (65.5%), with a mean age of 67.9±12.1 and medical comorbidities of hypertension (86%), diabetes (76%), and tobacco use (7%). The majority (86%) had prior angioplasty and 17 of 29 (59%) patients had previous central venous catheters. The right brachiocephalic vein was the most commonly stented vessel (28%). The median stent length and diameter used were 50millimeters (range 25-100millimeters) and 13millimeters (range: 9-13millimeters), respectively. The majority of patients (83%) received a single stent, with only 2 patients requiring more than one. Median follow-up was 24months (range: 6-41months). Four of 29 (13.8%) patients developed symptomatic stent restenosis requiring secondary intervention, all of which occurred in patients with primary stenosis between 50% and 75%. When compared to the patients without restenosis, longer stents were found to be significantly associated with restenosis (62.5centimeters, interquartile range [IQR]: 0] vs. 50centimeter, IQR: 0, P=0.002). Primary patency rates were 92.9%, 91.7%, and 80.0% at 6, 12, and 24months respectively. Secondary patency rates were 96.4%, 95.8%, and 93.3% at 6months, 12months, and 24months, respectively. The overall primary patency rate was estimated at 86.2% using Kaplan-Meier analysis at 30.5months (95% confidence interval: 26.5-34.5months). Covered stent grafts have reasonable primary patency and excellent secondary patency when used for central venous stenosis in dialysis patients. Stent-graft length is associated with poorer long-term patency rates.

Application of Intravascular Ultrasound in End-Stage Renal Patients with Central Venous Occlusive Disease.

Central venous occlusive disease is frequently observed in patients with end-stage renal disease. Venography remains the gold standard for diagnosis, but intravascular ultrasound is a potentially beneficial adjunct that may positively influence intervention.

Left axillary to right atrium anterior chest wall graft using bovine carotid artery conduit

Central venous occlusive (CVO) disease involving the superior vena cava (SVC) and inferior vena cava (IVC) can occur frequently in patients with end-stage renal disease (ESRD) on chronic dialysis. Dialysis access is essential for the survival of these patients. We report a case of a chest wall graft creation using bovine carotid artery conduit in a patient who was experiencing life-threatening loss of dialysis access secondary to her SVC and IVC occlusion along with a hypercoagulable state. We did a subcutaneous anterior chest wall graft from the left axillary artery to the right atrium (RA) using a mini thoracotomy incision. ESRD patients with CVO pose a unique challenge. We believe our approach can provide an excellent option for dialysis access in patients with exhausted conventional access options.

Single versus dual access as endovascular techniques in the management of challenging central venous occlusive disease: success rate and efficacy

Single versus dual access as endovascular techniques in the management of challenging central venous occlusive disease: success rate and efficacy

Early cannulation graft Flixene™ for conventional and complex hemodialysis access creation.

The Flixene™ (Atrium™, Hudson, NH) is a trilaminate composite polytetrafluoroethylene (PTFE) graft that allows access within 72 hours. We evaluate our initial experience with this device for conventional and complex hemodialysis access creation. Retrospective review in end-stage renal disease (ESRD) patients who underwent access creation with Flixene from January 2013 to July 2014. For our analysis, the patients were divided in two groups: those with complex access configurations tunneled in the chest and/or abdominal wall (thoraco-abdominal wall access [TAWA]), and those tunneled in conventional sites (extremity access [EA]). Patient's demographics, indications, complications, reinterventions, patency rates and factors influencing outcomes were evaluated. In 19 patients (54% men; mean age 44 years ± 18), 24 grafts were implanted, (13 EA [54%] vs. 11 TAWA), all patent after surgery. Central venous occlusive disease (CVOD) was present in all patients with TAWA and in 7/13 (54%) EA patients (p = 0.016). Early cannulation (within 72 hours) was successful in 12 EA and 5 TAWA grafts (p = 0.044). Complication rates including infection, thrombosis, bleeding and steal syndrome were 8/11 (73%) in TAWA and 5/13 (38%) in EA (p = 0.02). At 12 months, primary patency rates for EA and TAWA were 25% and 41%; secondary patency rates were 55% and 41%, respectively. Early cannulation (EC) grafts are viable alternatives for conventional and complex access creation that allowed early cannulation (<72 hours) in 17 (70%) of our cases. Primary and secondary patency rates at 12 months were equivalent to data reported on ePTFE grafts.

Percutaneous transluminal angioplasty in haemodialysis patients with central or peripheral venous stenosis

Dysfunction of arteriovenous fistulae (AVF), which result from peripheral or central venous occlusive illness, occurs very often in haemodialysis patients. In therapy, endovascular open procedures are prefered. Our study illustrated the clinical success of percutaneous transluminal angioplasty (PTA) for the treatment of these patient. A retrospective analysis was applied on patients presenting during a 2-years term with haemodialysis failure and ipsilateral arm swelling coherant with peripheral and/or central venous stenosis. PTA was performed as clinically and angiografically indicated. Technical success of PTA was defined less than 30% residual stenosis and clinical success was illustrated by resolution of pain and edema along with preservation of the AVF. Our study shows a subgroup of 26 patients that presented with symptomatic peripheral or central venous occlusive disease. Mean follow-up was 12.4 months (range, 3-24 months). PTA was successful in 26 patients 11 of whom were with central lesions and 15 of whom were with peripheral lesions. We were stated for central lesions PTA had a priority patency rates of 81.8%, 60%, 37.5% and supported primary patency rates of 90.9%, 70%, 62.5% at 3, 6, 12 months. For peripheral lesions, primary patency rates of 86.7%, 78.5%, 66.6% at 3, 6 and 12 months and assisted primary patency rates of 93.3%, 85.7% and 75%, separately. PTA for central and peripheral venous stenosis is be a successful and safe procedure in hemodialysis patients. In patients with lesions that are responsible for dilation, continuous functional access in the affected extremity is sustained, especially for patients with peripheral venous stenosis.

Stent-supported percutaneous transluminal angioplasty in patients suffering from symptomatic benign or malignant central venous occlusive disease

Background The aim of this study was to investigate the outcome of patients suffering from benign or malignant superior vena cava (SVC), brachiocephalic (BCV), and subclavian (SV) vein lesions treated with nitinol stents.

Percutaneous management of chronic central venous occlusive disease.

Stenosis or occlusion of the central veins and/or vena cava can cause painful and debilitating symptoms for affected patients. Superior vena cava syndrome (SVCS) can develop acutely or progressively from external compression or intrinsic obstruction. The clinical signs and symptoms result from venous hypertension and reduced blood flow in the superior vena cava (SVC) or central veins emptying into the SVC. Depending on the anatomic location of the narrowing, clinical symptoms, and presentation will vary. Clinical signs include cyanosis, plethora, distention of subcutaneous veins, and edema of the upper extremities, head and neck. Edema may compromise laryngeal or pharyngeal function, causing dyspnea, stridor, cough, hoarseness, and dysphagia.1 Although there may be symptom overlap with congestive heart failure, a physical examination will usually delineate between the two diagnoses. The etiology of SVCS varies and can be broadly grouped into benign and malignant causes, with most strictures of the caval system and venous tributaries being malignant.2 3 Non–small-cell lung cancer (NSCLC) is the most common malignant cause of SVCS, followed by small-cell lung cancer (SCLC) and non-Hodgkin lymphoma.4 The most common causes of benign venous stenosis involve the presence of an indwelling intravascular device (i.e., catheters, pacemaker/defibrillators, ports). Arteriovenous fistula related obstruction, mediastinal fibrosis, and prior thoracic external bean radiation therapy are additional benign causes. Treatment of central venous occlusions depends on the etiology and clinical presentation. The ultimate goal of therapy is to correct the obstruction and alleviate the symptoms. Conservative measures depend on the etiology and include limb elevation, steroids, anticoagulation, chemotherapy and/or radiation therapy, and diuretics.5 Interventional therapies include surgical bypass and/or endovascular stent placement. Guide wire recanalization and endovascular stenting is a minimally invasive procedure that can be performed on an outpatient basis with standard equipment available in an angiography suite. The procedure below describes the authors approach to treating chronic central venous occlusive disease.

The real cost of treating venous ulcers in a contemporary vascular practice.

Venous leg ulcers (VLUs) are a prevalent and morbid disease that consumes considerable health care resources. Estimates place the total costs for treatment of VLU at 1% of health care budgets in many industrialized countries. Unfortunately, there is little contemporary information on the total cost of treating VLU in the United States, particularly in a wound center staffed by vascular specialists. The purpose of this study was to define the actual cost of treating VLU and to identify factors influencing costs. A cohort of 84 patients with active VLU (Clinical, Etiologic, Anatomic, and Pathologic class 6 disease) who were treated in a wound center by five vascular surgeons with a minimum follow-up of 6months (median, 368days; range, 336-483 days) was retrospectively studied. Actual costs (not charges) were obtained for outpatient and inpatient facility, visiting nurse services, and our physician practice group to yield true cost. The proportion of healed VLUs and time to complete healing were determined to calculate time to healing as well as ulcer-free intervals. Calculations of cost/ulcer-free days and cost to complete healing for the entire follow-up period were carried out as well as univariate analysis of factors affecting cost. The mean total cost of treating VLU during this follow-up period was $15,732. A total of 50 patients (60%) healed their VLUs without recurrence in a mean time of 122days (range, 6-379days) at a cost of $10,563 (range, $430-$50,967). This translated to $86/day of treatment to heal an ulcer, resulting in a cost of $42/ulcer-free day. In comparison, the total cost was threefold higher at $33,907 (range, $390-$132,730) for the patients (n= 17; 20%) who did not heal their VLUs. Significant contributing factors included outpatient facility fees ($10,332) and visiting nurse services ($11,365) related to extended treatment of the open VLU. Patients who had a recurrence of their VLU (n= 17; 20%) during the follow-up period had a total cost of $12,760. Inpatient admission for wound-related issues increased total cost to $33,629. Nearly two thirds of admissions were for treatment of cellulitis with intravenous antibiotics. VLUs treated with surgical intervention did not significantly increase total cost ($12,304 vs $19,503; P > .05) but significantly reduced recurrence rates (34% vs 5%). There were three outliers who experienced complications after treatment of outflow obstruction that dramatically increased the total cost to $71,526. This economic analysis demonstrates the high true costs associated with modern treatment of VLU by aggressive medical and surgical techniques. Inpatient and outpatient facility fees, physician fees, and visiting nurse payments all contribute to the cumulative tally that results in these staggering direct costs for treatment of VLUs. The daily cost of treatment that accrues for the ongoing care of VLU patients until they are healed provides an economic rationale for initiatives that advance approaches seeking to provide more rapid wound healing. Our analysis also highlights the significant costs associated with treatment of infections and complications encountered in aggressive surgical interventions for patients with extensive chronic central venous occlusive disease. More aggressive early outpatient treatment of infections and refined criteria for selection of outflow stenting candidates may reduce total cost by preventing complications while improving outcomes.